03120060 (2) CITY OF CUPERTINO "
BUILDING DIVISION PERMIT tiCON,'TRACTOR INF�ORMAT,10
BUILDING ADDRESS: PERMIT NO.
03120060
NEWS NAME: PERMIT ISSUE DATE
HOLLY FREDRICKS NE: SANITARY OL NO.
ARCHI'IYC IENGINEM: BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
]
"oGZp LICENSED CONTRACTOR'S DECLARATION
I 1 Mreby Allan n
that 1 am limemme
d under provisions of Chapter 9(commencing with
Description
IN Section 7")of DfAim.3 of the B.4.And Professiona Codd.and my Timm b
mfail fomeAnd effect. GUEST BATHROOM REMODEL
,j b License Clan Lie.N
t Dau y0ractor
TSConDELL ARCHI'TECT'S DECLARATION
Y 1 understand my plana alull to used As public mcmda
3
red Lianand Professional
OWNER-BUILDER from
DECLARATION
1 heresy.(firm that I . exempt Bum tha Contrumr's :Any C Law for the
o o fallowing reason.(Section RDI.S,Business and Rofcuuns Code:Any city or county
$ which mqusea•permit re lumai the
Aur.Impmw,dePermit
t ri repair any mKWfe
vy' prim In itsissuance,pursalso uant
to the posvis "Orthicant nuchpcmi's U. .Ile ..(Ced htemem
that ma cCenr�A purtuant 70M)of Diviomaf tMCenuacesslan mnso law lChapter9 � Sq:At.,Fl00r Area ValUa On
63$
Chat
I.exemping t ion 3
oftheBedexem don.A.inna CMc)m v ~ +*
Ijl Nn he u.umpl therefrom and the buns Inc the alleged exemption.Any violallon of '�'•1
Section 7031.5 by any applicant for a permit Subjects the applicant m a civil penalty of - 3 X010 0 Occupancy Type
Ammore Nu 0w hundred dollars(8500).
01,As owner of the property.or my..play.with wguu their role mmpenulion
will the the work,and the moneache 4 net intended moIered fm We(Sec.7044.Business
and Pmfu,lmu Code:The ConuumY,License law toms not apply lf an owner of U I+ - Req Inspections
pmputy toyack ldaarimpmt suchtwereem,andwho
meats dahhuehwmk himW far through his u
ownemplayeW iprovided that such improvements in not lntendW or m.leered for muncr.
however.Nebuildingorimpmwmentihhold within am yam of mproe err Ne.suers J
builder will have the burden of proving that he did trot Wild m Improve fm purpose of J
uuJ.
JS 1,u owner of tiro property,am exclusively mounting with licensed commuc an to
construct the pmjM(Sec.7044.Business and Professions Code:)The ConvacuYh Li-
cenu law does not apply in an owner of property who baldf or Impmw therein,and
who contracts for such projects MN a cone,cmr(s)limnand pursuant in site Contractor',
License law. - ..
1 am exempt under Sec. .B&P C horn thisrecon
.clu•nor Data
cri RKER'SCOMPENSAD RATION
1 bermy,f(lrm under penalty of perjury em of the following declarations:
❑I hawend will malnuin a CeNficauaf Conxnlm sulbinsum fm Worker's Compem
Salon.an provided for by Section 3700 of the labra Code,for the,performance of the
work for which this permit is woad.
❑1 have and will maintain Worker's Compensation InauranCe,as required by Section
37M of the labor Code,for the performarme of the work for which this permit is iuuW.
My Worker',Compensation Insurance carrier and Policy number am:
Carrier. Policy Nu:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
iThissectlon need nut becompleted doe Permit Is foram hundreddallan(SIM)
or leak)
1 Certify tlut in Ne perfmmeme of om work for which this Permit is(mad.I shall not
employ any person in any mamefan as in become subject in the Workers'Compensation
Law.of California.Dau
Applicant
NOTICE TO APPLICANT:If.after making tub Certificate of Exemption,you should
become subject ro she We&.'.Compenawon provisions of the Labor Code,you mut
.JZ forthwith comply with such provisions of Nb permit shall he deemed revalued.
?O CONSTRUCTION LENDING AGENCY
[-i I hereby affirm that time,is a Construction lendingagemy for tM performance of
C> the work for which this permit Is issued(Sm.3097.Civ.C.)
WM Q Lender'.Name
.7. Z Lendersing ABdmns
U Q 1 modify that I ham mW this application and arm that the above information is
D,U correct I Spa m comply with all city and county ordinances and funs Inn h bring to
Wildingconstruction.ad and rot by inspechm purporepretenutiws of this City m enter upon urs
W shove (We)
to cnysaw,foremnify an keep A.
ha
(sju agme u naw,indemnify and kap hamlM the City of against against
Uy in
fthetoauand expenses which may In any wySame against aid City
(„)'[ A APPLICANT
of the Starting of this per mit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL/NON-POINT Issued by: Date
s URC,FR LAn�S, .1, V 1y,t/9 Re-roofs
Signuureof Ap ndCantr¢mr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding asupanr mom m Modle haurdous material
as defined by de Cupertino Municipal Calc,Chapter 9.12.and the Health and Safety
Code.Section 25532(.)] All roofs shall be inspected prior to any roofing material being installed.
❑Yex PNo
Will the applicant or furore building occupant use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazard..,alr maumimnu as&food by the Bay Arta Air Quality Management all new materials for inspection.
Dimfict7
❑Yes 9Nu
I have rad the haardous materiaisrequmm ax under Ch,pter6.95 ofdm Califon v
ni.Hmlth&Safety Cale,Seedou25N15.25533aa25534.lundefmaM ifthe building
does our Connally haw a tenant that it is my responsibility to notify tM occupant of the
mquirem ¢which mum an tpdorw"ssumme of CwOcamof Occupan Signature Of Applicant Date
water or mtho y agent Dam
All roof coverings to be Class"B"or better